The objectives
of this historical-social study are: to describe the circumstances that determined
the participation of North American nurses in the formation of the Brazilian
nurse; and analyse the process of implementing institutional rituals as a strategy
of symbolic fight, to confer visibility to the nurse profession and discuss
the symbolic effects of institutional rituals for the consecration of a nurse
model for Brazilian society at the time. The primary sources are constituted
of pertaining written and photographic documents relative to the studied theme.
By reading the documentary corpus an analysis was made of the symbols that had
distinguished and established the hierarchies of the actions, as well as the
strategies undertaken for the North American nurses, towards implementing a
new model of nurses in Brazilian society, coherent with the model of the North
American schools of nursing. Institutional rituals, conducted or testified by
prestigious figures of the history of Brazil and nursing, were fundamental for
the construction of professional identity.

The establishment
of modern nursing in the Brazilian capital at the start of the 1920's occurred
under the auspices of public health, in the context of a held reform led by
the former Director of the National Public Health Department (DNSP), the health
surveillance physician and scientist Carlos Chagas. In that context, the new
conception of public health, as well as sanitarist physicians' participation
in Brazilian health issues, appointed the need for a new agent, whose personal
and professional determinations permitted that group's proposal to complement
physicians' work through health surveillance care and sanitary education for
patients treated at dispensaries of the federal government in Rio de Janeiro,
through home visits(1).

That reform offered
the opportunity for a group of North American nurses to visit Brazil as participants
in the Technical Cooperation Mission for the Development of Nursing in Brazil.
The mission remained in Brazil for one decade (1921-1931), simultaneously working
on three fronts: the organization of a unified public health nursing service,
on the same hierarchical line as other DNSP inspectorates; the creation of the
DNSP School of Nursing, today Escola de Enfermagem Anna Nery, in line with North
American nursing teaching standards; and the reorganization of the DNSP's Hospital
Geral da Assistência, to serve as a training area for nursing students(2).

The creation of
Escola de Enfermagem Anna Nery, in 1992, led to the transposition, to Brazil,
of a nursing model that combined the characteristics of the traditional Nightingale
model with others developed during its adaptation process to the American society
since the times of the civil war(3).

Across a decade,
the American nurses struggled to build the image of a solidly prepared nurse,
even going against many physicians inside the DNSP, who merely wanted to solve
the most immediate problems in their daily practice. In that struggle, it was
verified that the training process of Brazilian nurses included strategies aimed
at granting visibility to the emerging profession in the Brazilian society,
through the establishment of rituals and emblems of the profession and the adoption
of strict discipline, which modeled the behavior of future nurses(3).

To study this problem,
the following goals were set: to describe the circumstance of North American
nurses' participation in Brazilian nursing education; to analyze the implantation
process of institutional rituals as a symbolic fight strategy, to grant visibility
to the nursing profession; and to discuss the symbolic effects of institutional
rituals for the consecration of a nurse model in the Brazilian society at that
time.

METHOD

The primary sources
for this historical-social study were written documents, such as school board
reports for 1923, 1925 and 1927, filed at the Documentation Center of Escola
de Enfermagem Anna Nery at Universidade Federal do Rio de Janeiro(4-6).
The two photographs, also part of the documentation center's collection, were
included in the document corpus because they exemplify the importance of institutional
rituals for the visibility of Brazilian nursing, through the presence of renowned
characters of health history, such as Carlos Chagas, during the school's solemnities,
and the photograph of students and teachers in front of an important building,
which the group appropriated itself of as a symbolic good.

In line with the
historical method, the study covered three essential phases: data survey; critical
data analysis and conclusions. Thus, after the selection and classification
of the documentary sources, the quality and relevance of the information in
these sources was determined with a view to the proposed historiography research.
This source validation process is called external criticism and internal criticism.
External criticism questions a historical document's authenticity and, in that
sense, considers its authorship, origin and nature. The aim of internal criticism
is to apprehend the document's contents, meaning and veracity(7).
Moreover, secondary sources, including papers and books, supported the analysis
of data from the primary sources, which constituted the documentary corpus.

In the data analysis
phase, the set of political, social and sanitary facts was taken into account
to interpret the historical data, which permitted the historical exposition
based on the selected documents. The French sociologist Pierre Bourdieu's thinking
served as the theoretical framework, especially the concept of habitus.
His central argument is that social practices are structured, that is, they
display properties typical of the social position of who produces them, expressed
through the habitus, which translates the intrinsic and relational characteristics
of a position in a univocal lifestyle, that is, in a univocal set of choices,
goods and practices(8). Thus, the habitus works as a set
of distinctive traits and distinguished separations, which constitute a mythical-ritual
system and symbolize individuals in social spaces.

Thus, the effect
of the statutory attribution the institutional rituals granted which, by consecrating
a new identity, imposed the incorporation of a habitus in line with what is
expected from the consecrated person - measuring up to his new position, were
themes addressed in the analysis of the document corpus.

This study derives
from the research project "Emblems and Rituals in the Identity Formation of
Brazilian Nurses", which got Institutional Review Board approval at Escola de
Enfermagem Anna Nery / Hospital São Francisco de Assis on August 31st
2004. Protocol No 017/06.

RESULTS AND
DISCUSSION

The forces at
stake in the federal capital and the arrival of American nurses

At the start of
the twentieth century, Rio de Janeiro, former capital of Brazil, was the only
large city and differed from other Brazilian cities because of its banking network,
as a trade and industrial development hub, and because it offered the largest
railway network in the country. This condition derived from the proximity of
raw material suppliers, capital accumulation resulting from agriculture or foreign
trade and the existence of a considerable consumption market in the city itself
and regions bordering on the railways. Also, plenty of workforce was available
due to foreign immigration(9).

This large group
of Brazilian and foreign immigrants, however, constituted a permanent focus
of tension regarding employment opportunities, as the most promising and non-eventual
activities were reserved for foreigners. In addition, these many immigrants
aggravated the city's chronic problems, including lack of water, sanitation
and insufficient housing. The city's geographical shape, cut by hills, bays
and mangroves, also worsened the problems deriving from population growth and
hampered the city's expansion. Consequently, the rise in housing prices made
the poor population establish itself in collective and unhealthy facilities,
in the center and port areas of Rio de Janeiro(10).

What added up to
this critical picture were the repercussions of the first world war, accompanied
by the interruption of foreign capital when Brazil had to comply with external
debt commitments. Inside the country, for popular classes, this brought down
wages and increased the cost of living and unemployment rates(11).

The situation was
aggravated even further when, in September 1918, a flu epidemic arrived from
post-war Europe, called the Spanish flu, which led the city to chaos and disclosed
the public apparatus' inability to cope with health, considering that, in less
than two months, more than two-thirds of the population was affected, killing
approximately twelve thousand people(12).

The press reported
on fatal cases, criticized public services' activities and accused the government
of unlawfully withholding information on the true situation of the epidemic.
Also, Brazilian health surveillance physicians were concerned with the publication,
in 1916, of the Report on the sanitarist physicians Arthur Neiva and Belisário
Pena's Medical-Scientific Expedition to the regions chastened by draught in
Northern Bahia, Southern Piauí and Northern and Southern Goiás
in 1912. This report reinforced the impression the work by Euclides da Cunha
called Os Sertões (1902) had left, which showed the precarious living
conditions of the population in the Brazilian inland(11).

Thus, health and
sanitation turned into national themes and created the opportunity for a movement
called Pró-Saneamento do Brasil, led by health surveillance physicians,
which joined a large number of intellectuals, physicians, politicians, journalists
and scientists and demanded the organization of an administrative apparatus
in health and the State's more active participation through stronger actions
against diseases(13).

The president-elect
Epitácio Pessoa (1918-1922), committed to the sanitarist movement, created
the National Public Health Department in 1920, establishing sanitary practices
inside the State apparatus and permitting the political rise of the medical-sanitary
intellectual circle, which started to influence health decisions in Brazil and
was led by the renowned scientist Carlos Chagas, nominated to lead the department(9).

The sanitary reform
Carlos Chagas led took place between 1920 and 1924, through a series of decrees,
issued in the attempt to redefine the State's role in Brazilian health issues.
In this context, the cooperation program with the Rockefeller Foundation started
in the federal capital and the replacement of the sanitary policy by the sanitary
education concept.

Meanwhile, Lewis
Wendell Hacket, former director of the Rockefeller Foundation's International
Health Council, encouraged Carlos Chagas to get to know nurses' contribution
to prophylaxis campaigns in the United States, intermediating negotiations with
the Rockefeller Foundation, which had been working in Latin America since 1915,
to arrange for the visit of a mission of North American nurses to Brazil. Underlying
this decision was the premise that population health did not only depend on
sanitary campaigns, but much more on professionals' quality. In that sense,
Wicklife Rose, from the Rockefeller Foundation, established primary contacts
with nurse Ethel Parsons, former head nurse of the Child Hygiene and Public
Health Nursing Division in Texas, inviting her to lead a mission of nurses that
would come to Brazil(4).

Parsons arrived
in Rio de Janeiro on September 2nd 1921, starting a diagnosis of
the situation, according to which nursing schools in the federal capital did
not adopt the minimal nursing standards that existed in Anglo-Saxon countries;
hospitals were overcrowded and both male and female persons practiced nursing,
without any professional preparation; she also found that DNSP physicians working
at tuberculosis, venereal disease and child hygiene services had hired 44 girls,
some with low education levels, who, after twelve lectures they offered, started
to work as visitors(1).

During the North
American nursing mission's stay in Brazil, Parsons served as the General Superintendent
of the DNSP' Nurses service, centralizing nursing command. Nevertheless,

the work to set
up modern nurses had to be done in stages and through strategic approaches,
including the effect of practical (care and public health) demonstrations
on the utility of solidly prepared nurses(1).

According to Ethel
Parsons, the nurse was the central figure in teaching on the sanitary doctrines
in force in the civilized world, which were necessary to preserve health, emphasizing
that the nurse's aptitude was based on her ability to teach through demonstration,
in view of her hospital experience(4).

During its stay
in Rio de Janeiro, the North American nursing mission significantly contributed
to the doctrinaire inculcation and technological importation project in health
and education, at the heart of capitalism, within a conjuncture under strong
American influence(1). This indoctrination process exemplified North
American nurses' fight to impose the legitimate view, through power relations
established among agents, which at bottom derives from and is proportional to
the symbolic capital accumulated across the social trajectory.

Establishment
of institutional rituals for Brazilian nursing

During the North
American nursing mission's activity period, Claire Louise Kieninger (1923-1925),
Loraine Geneviéve Dennhardt (1925-1928) and Bertha Pullen (1928-1931)
served as the deans for what is currently Escola de Enfermagem Anna Nery, inaugurated
on February 19th 1923. The latter's term in office was a prorogation period
of the mission in Brazil, as the initial agreement determined 1928 as the contract's
end date(1).

The course took
two years and four months. The first four months were an experience period,
during which the student could be disconnected at any time, left to the school's
dean. The cap reception ritual marked the student's actual integration into
the student group. The excerpt from one student's speech, who belonged to the
pioneering group at Escola de Enfermagem Anna Nery, when the first reception
ritual of the school cap was held in 1923, evidences the incorporation of a
habitus in line with Christian ethics, reinforcing their new social condition:

It means that
you belong to the class of those who, forgetting about themselves, seek the
welfare of those who suffer, it means that you belong to a class that has
been trained and educated to repress one's own desires for the common good
and that you grow in your heart a well of goodness and energy. You already
are no longer fully master of yourself, everything you will do will fall back
on your class(5).

The graduation
of the first group of nurses from Escola de Enfermagem Anna Nery, in June 1925,
was celebrated through religious, professional and social events, which joined
civil, religious and military authorities. Thus, on June 19th, the
archbishop of Rio de Janeiro celebrated a solemn mass at the mother church of
Candelária. The graduation ritual included different moments: the opening,
while the hymn of nurses was performed, student members entered the premises
in ascending order. After Carlos Chagas' speech, D. Sebastião Leme blessed
the degrees and badges. After the class speaker's speech, all participants sang
the national anthem. Also, a gala ball was held at an elite club in Rio de Janeiro(6).

During the graduation
ritual, the lighted lamp, which evokes Florence Nightingale, passed through
the hands of each graduate before being passed on to the class of candidate
students. The lamp transfer, which symbolized the shared commitment to keep
alive the ideals of the profession, reinforced the student's vote, commitment,
faith and fidelity towards the institution and nursing, turning the moment more
severe(6). The next day, the busts of Carlos Chagas and Claire
Louise Kieninger were inaugurated, as well as a plaque that rendered tribute
to Ethel Parsons. Picture 1 registers the event, which took
place outside the salão nobre of the Students' Boarding House in the
neighborhood Tijuca.

At the center of
this posed picture are the busts of Claire Louise Kieninger and Carlos Chagas
and the plaque for Ethel Parsons, stating: To Mrs Parsons - The great organizer
of the Modern Nursing Service in Brazil, a Tribute from the 1st Class
of Brazilian Nurses 06/19/1925.

The Brazilian flag
rests on the bust of Carlos Chagas, revealing the final letters of the legend,
and the American flag on the bust of Claire Louise Kieninger. The honored persons'
individual attributes and their respective countries' flags reinforce existing
alliances between both and the valuation of American nurses' participation in
the establishment of a nurse model for the Brazilian society.

Beneath the valuation
of women and nurses, which the importance of the event granted, it was evidenced
that the honored persons represented the roles men and women were attributed
in society, as one of the graduates' speeches highlighted Carlos Chagas' intellectual
attributes, emphasizing the benefits of what he accomplished for Brazilian progress,
while the words directed at Claire Louise Kieninger underlined attributes like
goodness, kindness and honesty, as shown in the following excerpt:

It is with pleasure
that our school fulfills the duty of highlighting and appointing the rare
abnegation, the unique distinction, the diamante character, the excessive
delicacy, the noble appearance, the honest figure, the extreme dedication,
the evangelical patience, the maximum tolerance, altruistic endowments and
uncommon perfection of our Kieninger.

This division of
roles and qualities imposed on women start in the context of family life, when
it is tacitly established that the woman's role should be that of affectionate
caregiver, besides organizer of mechanisms to satisfy different family members'
physiological and affective needs(14). In that sense, the issue of
sexual difference can be understood as a result of a social construction of
men and women's roles, through principles that enunciate and represent the social
division of work as natural, which tends to ratify male domination(15).

Efforts were also
made to safeguard the image of nurses through architectonic devices, surveillance
and standards. The buildings were symbols of power and disciplinary control,
through the school architecture itself, which took the form of a program that
talked to the agents, establishing, in its material form, a value system, like
order and discipline(16). Picture 2 shows a group
of students after the Cap reception ritual, against the background of the stairs
at the main entry of the Student Boarding House, in 1927.

The Student Boarding
House (former hotel Sete de Setembro, in the nieghborhood Flamengo, built to
host foreign delegations on the occasion of the celebrations for the Centenary
of Brazilian Independence, in 1922), which Escola de Enfermagem Anna Nery received
in 1926, and the Class Pavillion (three-flour building with classrooms and laboratories),
built near Hospital São Francisco de Assis in the neighborhood Cidade
Nova and inaugurated in 1927, exerted place effects, serving as symbolic goods
for the nurses, who located them in the social space, as the space is one
of the places where power is affirmed and practiced(17).

Hence, the ownership
of these architectonic monuments aimed to capitalize on power and prestige by
perpetuating Brazilian nursing monuments. In that process, memory is turned
sacred and converted into a symbolic good for the group. Transmitted as a heritage
through celebrations, it contributes to reinforce the nursing group's feeling
of unity and, consequently, a feeling of statutory filiation.

Symbolic effects
of the consecration of Nursing rituals in the Brazilian society

The rituals and
emblems of the profession, which the North American nurses established since
the inauguration of Escola de Enfermagem Anna Nery in 1923, mainly served to
consecrate a new symbolic order, as rituals entail statutory deposit effects,
since they mark not only the passage from one state to another, but determine
the incorporation of a professional habitus in line with social expectations
regarding the profession(18).

In that sense,
institutional rituals reaffirmed the student's commitment to the profession
because they represent communication acts that notify someone about his/her
identity(19). Thus, the cap or the degree, as distinctive marks
of students and nurses, entitled them to a right to be according to an established
identity, which represents the learning of an adequate habitus for their
new social position.

Hence, one of the
traits that marked the North American deans' term in office at Escola de Enfermagem
Anna Nery, was the implantation of rituals and emblems (Cap Reception, Graduation
and Inaugurations), already established in their country, during solemnities
that joined people from different Brazilian and American social spheres, turning
the group manifest to itself and other people. That is the case because the
consecration of the group, granted by the rituals, depends on the power of the
authorities who establish it and on the receivers' willingness to get to know
and acknowledge the institutional conditions of a valid ritual.

The rituals' symbolic
efficacy rests in the fact of acting on the real by acting on the representation
of the real(19)), as rituals, by establishing differences, transform
other people's representation of the consecrated person by modifying mainly
the behaviors they adopt towards him/her. At the same time, the investiture
transforms the person's representation of herself, as well as the behaviors
she believes she is obliged to adopt in order to adjust to that representation.
Therefore, rituals are responsible for reinforcing the social bonds among individuals
and the group they are inserted in, entailing a kind of reaffirmation of a social
group's identity(19).

The different social
groups tend to endow themselves with means that allow them to endure beyond
individual agents' finiteness, through the use of symbolization and immortalization
instruments(8) as reference points to express and inculcate, intentional
or implicitly, a social identity. In that sense, the light that keeps alive
the memory of Florence Nightingale, the precursor of modern nursing, who during
the Crimean War passed through field hospitals' infirmaries at night to help
the victims of war, present in the rituals of Escola de Enfermagem Anna Nery
since its establishment, celebrates and transmits the history of a global nursing
personality to posterity, which should be known, learned and reminded.

Moreover, the promotion
of nursing figures and facts through statues and portrait inaugurations aimed
for and resulted in the appropriation (like in the case of Carlos Chagas) or
construction of mythical figures (prestigious North American nurses) as models
to be followed. This strategy also contributed to consecrate the founders of
Brazilian nursing, preserving their memory for posterity, as the portrait
or statue immortalizes the person it represents(8) and permits
capitalizing on symbolic profits deriving from the effects of immortalization.

These strategies
were combined with the planning and control of students' actions in regulated
and regulatory spheres. Through this educative work, social constructions were
incorporated and therefore inscribed on the students' bodies as a system of
dispositions, a habitus, principles producing practices and the appreciation
of practices. Thus, the habitus works as a grammar that produces distinct
and distinctive practice, which the subjects' actions reflect and which update
the marks of their social position and structural distinctions that define them.

Besides, these
strategies contributed to strengthen the group's feeling of internal unity,
through the standardization of attitudes and gestures(20), which
were considered indispensable for the nurse model and compatible with the moral,
social and sanitary standards at that time. Thus, ethics and esthetics were
constructed, underlying the effort to teach the students how they should behave
as nurses, with decent gestures and looks, adequate ways to smile and talk.
Besides, the nurse's uniform combined with the demand for a discrete, dignified
and homogeneous posture. Therefore, the incorporated signs that cover the ways
of talking, pose, posture, economy of gestures, combined with external body
signs like uniforms, medals, armbands, etc., symbolize nurses' social position
through distinctive differences that grant them social acknowledgement.

It should be highlighted
that the Nurse's Hymn, lyrics by Maria Eugênia Celso and music by Eduardo
Couto, sang during these rituals, represented a strategy aimed a proclaiming
the nascent profession's identity in the Brazilian society, also because the
ritual, as a set of formalized and expressive acts with a symbolic dimension,
uses a system of languages and specific behaviors as a resource, as well as
emblematic objects, whose sense represents a symbolic good for the group, contributing
to its establishment and consecration(19).

Excerpts from the
Nurse's Hymn evidence strategies of religious devotion and exaltation of attributes
intrinsic in women's nature, such as charity and abnegation, which are also
considered important to legitimize that women go out to work: And all nurses
will be the messengers of God's love; provide shelter, consolation is the lemma
of our lives and the glory of our profession(6). Thus, the valuation
of female attributes in professional practice, implicit in the division of sexual
roles, which should guide nurses' daily work through discrete, silent, generous
and unselfish care, evidenced great material and symbolic division of the social
world.

Underlying the
institutionalization effect of rituals and emblems, the Nurse's hymn contributed
to legitimize women's insertion in health, through the valuation of religious
and patriotic attributes, as a successful strategy to disseminate nurses' good
image to the Brazilian society(21). And that is the case because
the rituals, as symbolic manipulation strategies, that is, represented in things
like hymns and public acts, intended to determine the impression that other
people should have these properties and their bearers, so as to create mental
representations and social manifestations, in line with the properties presented
as such.

In that sense,
the so-called liturgical conditions ruling the way rituals are manifested, such
as people's etiquette, the order of rituals, the presence of authorities and
the order of speeches, hymns, the composition of tables and emblems like flags
and insignia, constitute important visible elements to create mental images
of the institution and consecrated people.

Thus, the North
American nurses' consecration of a nurse model for the Brazilian society in
the 1920's comprised the establishment of institutional rituals and the adoption
of strategies aimed at processing a transformation in the candidate nurses'
habitus. In practical terms, these strategies contributed to make the
nascent profession known and acknowledged by society at that time. To the extent
that, at the end of the North American nurses' mission to the capital of Brazil,
in 1931, Escola de Enfermagem Anna Nery offered a solidly developed teaching
program and had graduated 73 nurses, approximately 17 of whom were taking graduate
programs in the United States. In terms of limitations of the mission's work
in Brazil, based on the analyzed data, it is observed that the desired incorporation
of Escola de Enfermagem Anna Nery into Universidade do Brasil, upon its creation,
was not achieved. Nevertheless, the dissemination of the school model was guaranteed
when Escola de Enfermagem Anna Nery was granted the condition of official standard
school (Decree 20.109, issued on June 15th 1931).

CONCLUSION

At the end of the
North American nurses' mission to the federal capital in 1931, nurses graduated
from Escola de Enfermagem Anna Nery demanded the positions of power American
nurses had occupied inside the School and in the DNSP. Although the American
presence corresponded to the imposition of a hegemonic worldview, it contributed
to the valuation of the nursing profession in the Brazilian society.

The establishment
of a new nurse model in the Brazilian society was accompanied by a set of strategies,
aimed at constructing a group identity, so as to make the profession known and
socially renowned. In that sense, the promotion of nursing facts and figures
aimed for and resulted in the construction of symbolic capital, deriving from
important social contacts with sanitary authorities, like in the case of the
scientist Carlos Chagas. Besides, the construction of mythical nursing figures
as models to be followed, enunciated elements to identify the profession.

Hence, ritualistic
repetitions, like inaugurations, cap reception and graduation ceremonies, in
combination with the perpetuation and transmission of the profession's knowledge
and emblems (flags, statues, medals, hymns), witnessed by prestigious characters
in Brazilian and nursing history, were fundamental to construct the professional
identity.

At the end of this
study, a historical version could be elaborated on American participation in
the establishment of a nurse model for the Brazilian society in the 1920's.
It is important to continue research on the theme though, also in the Rockefeller
Foundation's files (foundation that sponsored the mission of American nurses
in Brazil) in the United States, with a view to a reading of the past based
on other document sources. Another study limitation was the impossibility to
reconstruct history based on subjects' testimonies, through interviews as, due
to the time elapsed, this data collection technique could not be used, which
would have contributed to enrich data analysis and discussion, through a confrontation
with other document sources used in this study. Besides, the versions and interpretations
developed here are but mere provisional truths, as experience cannot be recovered.